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The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
- A. Apply just a diaper.
- B. Double the clothing.
- C. Place a cap on their heads.
- D. Increase room temperature to 90 degrees.
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap (C) conserves heat by covering this key area, a standard neonatal practice. A diaper alone (A) offers minimal coverage, increasing heat loss. Doubling clothing (B) helps but is less effective than a cap for head protection. Raising the room to 90?°F (D) risks overheating. Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.
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When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?
- A. This is normal for an infant.
- B. This is too fast for an infant.
- C. This is too slow for an infant.
- D. This is not a rate for an infant but for a toddler
Correct Answer: A
Rationale: Infant pulse ranges from 120-160 beats/min; 145 (A) is normal with regular rhythm. Too fast (B) or slow (C) misaligns with norms. Toddler rates (D) are lower (80-130). Choice A is correct, per pediatric vital sign standards.
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
- A. Temperatures vary depending on the route used.
- B. Temperatures are readings of core measurements.
- C. Rectal temperatures are cooler than when taken orally.
- D. Axillary temperatures are higher than oral temperatures.
Correct Answer: A
Rationale: Temperature varies by route (A) e.g., rectal is 1?°F higher, axillary 1?°F lower than oral requiring documentation for accuracy. Not all are core (B). Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.
The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse?
- A. Radial
- B. Brachial
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: In infants, the brachial artery (B) is preferred for pulse due to accessibility and strength; radial (A) is weak and hard to palpate. Femoral (C) and popliteal (D) are less practical. Choice B is correct, per pediatric norms, ensuring accurate infant pulse assessment.
The patient wants to monitor blood pressure at home and asks the nurse's advice about how to purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
- A. You can apply the cuff in any manner.
- B. You will need to recalibrate the machine.
- C. You can move your arm during the reading.
- D. You will need to use a stethoscope properly.
Correct Answer: B
Rationale: Portable BP devices require recalibration (B) for accuracy, a key teaching point. Random cuff placement (A) or arm movement (C) skews readings. Stethoscopes (D) aren't needed for electronic devices. Choice B is correct, ensuring reliable home monitoring per nursing education.
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
- A. 30 to 60
- B. 22 to 28
- C. 16 to 20
- D. 10 to 15
Correct Answer: A
Rationale: Newborn respiratory rate is 30-60 breaths/min; rapid breathing within this (A) is normal if pink, warm, dry. Lower ranges (B, C, D) apply to older ages. Choice A is correct, per neonatal norms, guiding care planning.